Healthcare Provider Details

I. General information

NPI: 1730236977
Provider Name (Legal Business Name): PHYLLIS TERRY EISENBERG II BS RN, MEED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 09/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 N SUNNY SLOPE RD SUITE 290
BROOKFIELD WI
53005-4809
US

IV. Provider business mailing address

PO BOX 170911
MILWAUKEE WI
53217-8081
US

V. Phone/Fax

Practice location:
  • Phone: 262-754-9460
  • Fax:
Mailing address:
  • Phone: 414-795-4104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1884-125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number51189-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: